Human Error? Nice try Rolling Hills…

Article by J. St Amand: Rolling Hills Hospital in Franklin, Tenn., recently refused a lesbian woman the right to visit her partner, reported the Tennessean in a Dec. 21 article. Franklin is located about 20 miles south of downtown Nashville.

The psychiatric hospital went against new federal anti-discrimination laws when Val Burke was not allowed to visit her partner who was in facility’s residential unit. The U.S. Department of Health and Human Services created the rules, which include equal visitation and representation rights, in September.

“It was human error,” said Richard Bangert, chief executive officer of Rolling Hills. “They made a mistake. When I learned of it, I immediately met with my staff on Monday. We immediately made the change in terms of making sure that our policy was very clear.”

Bangert plans to apologize to Burke

While it is nice to see the hospital endeavoring to comply with Federal regulations, this was not a case of HUMAN ERROR. Does labeling this as human error contribute to our understanding of it? This is another incident of blame and train. “we met with the staff and made sure our policy was clear.” Is the spirit of the policy “DON’T discriminate against federally protected groups?” IF so, the employee has to remember who to discriminate against and who not to discriminate against. Hospitals need to examine our culture when it comes to patient empowerment. Who are we as hospital workers to make any determination who sees or doesn’t see a patient who seeks care from us? If we need to limit numbers of visits for practical reasons, we need to let every patient pick who they want to visit unless we need to protect the patient from someone for a legal or criminal reason. There should be no need for a non-discrimination policy because all of the processes should be built around discriminating against no one. Imagine if we bought tickets to a show and the venue told us we were only allowed to bring our mother, father or sister.
In terms of I-O Psychology, I would also like to point out that HR policies should also be adjusted in terms of bereavement benefits. Many hospitals limit bereavement payouts by listing those deaths that are covered. Mother, father, father-in-law…again, who are we to decide who is important to people? If the benefit needs to be confined give employees a certain number of requests for bereavement and let them decide who is important to them.
Elisabeth Taylor was married eight times. That gives her 8 husbands at least 16 mothers and fathers-in-law. In terms of justice, should she get all that time paid when these people pass away versus someone who only has a life long friend or cousin for whom they aren’t allowed to take time? Could all Elisabeth’s husbands visit her at Rolling Hills?

Empowered patients are partners in safety. We must take care not to let the hospital culture infringe on these powers. WE must look at things like visitor policies and hospital gown policies to make sure they are empowering patients and not making things more convenient or comfortable for those of us providing care.

In the past year I visited the ER after a knee injury. I hoped to get in and out, just confirming that nothing was seriously wrong. I had loose wide legged pants on. The nurse came in and handed me a hospital gown. I politely said “no thanks.” She was taken aback. “You have to put it on.” “Why?” I politely asked. “She was flustered. “So the doctor can examine you.”
I rolled my pant leg up to my hip. She still didn’t know what to do. My intent was not to make her uncomfortable but to avoid sitting there in the cold waiting for a doctor to look at me for 5 minutes and say I was fine. Being a nurse, the thought of putting on a gown that had been worn by hundreds of very ill patients was frightening to me. In my 25 year career I had seen many of these come out of the laundry service with tape and various other stains still intact. I told her to leave the johnny and that I would put it on if the doctor needed me to. I left an hour later without wearing the johnny.

One of the ways to increase safety in healthcare is to keep asking “why”. This needs to come from healthcare workers but we also need to hear it from patients. And we need to carefully think about our answers. One individual’s actions are not human error when it comes to discrimination and patient dis empowerment. These actions are a result of our patriarchal and controlling history and culture. It’s time to move on.

About this blog: You’ve heard of Leapfrog now there’s SafetyDog!

This blog will merge ideas from management, nursing, medicine and psychology (and many others) to offer a different view of patient safety. The author has a Masters in Industrial-Organizational Psychology, a graduate certificate in Error Science and Patient Safety and also a BSN in Nursing and has worked as an RN since 1985. All comments are welcome..you never know when one of your thoughts might save a life!

Patient Safety

IOM
Institute of Medicine..their 1999 report “To Err is human” started it all.

Leap Frog Group
The Consumer Reports for hospitals. Encouraging transparency and comparison of quality and safety.

ISMP
Institute for Safe Medication Practices. If you are looking for information on safe medication practices (and unsafe ones) they have great newsletters and other resources.

IHI
The Institute for Healthcare Improvement has an entire section on patient safety.

AHRQ
The Agency for Healthcare Research and Quality. Great site from the Department of Health and Human services. Contains research articles and safety guidelines and tools. The link is to Patient safety net

Healthcare Quarterly
Best practices and peer reviewed articles. Editor is a PhD from the University of North Carolina.